Broadening Your Perspectives

Transcription

1 Midwestern Society of Orthodontists Broadening Your Perspectives Orthodontics and Beyond Patrick M. Lloyd, DDS, MS Dean and Professor, Division of Prosthodontics University of Minnesota School of Dentistry Legislation Enacted 2009 Discipline title: Dental therapist Professional supervision: works under a collaborative management agreement with a dentist Dentist must be licensed Minnesota dentist No more than 5 collaborative agreements DDS responsible for all services authorized & performed Law specifies procedures that can be performed under general supervision and which can be performed under indirect supervision. Education: Baccalaureate or master s degree from a dental therapy education program approved by the Board of Dentistry or accredited by CODA or another board-approved national accreditation organization. Practice settings: Settings that serve low-income and underserved; dental shortage area Legislation Enacted 2009 Settings that serve low-income, uninsured, and underserved Critical access dental provider settings Dental hygiene collaborative practice settings (including medical facilities, assisted living facilities, FQHCs, selected community clinics) Military/veterans administration hospitals, clinics, etc. Private residences for home-bound patients Oral health educational institutions Clinics in which at least 50% of d.t. or a.d.p. patients consists of patients who: Are enrolled in a MN health care program Have a medical disability/chronic condition that creates significant access barrier Have no health coverage and have annual gross family income < 200% federal poverty level Scope of practice Under general supervision Oral health instruction & disease prevention education Preliminary charting of the oral cavity Radiographs Polishing Application of topical preventive/prophylactic agents, including fluoride varnishes & sealants Pulp vitality testing Application of desensitizing medication or resin Mouthguard fabrication Place temporary restoration Fabricate soft occlusal guards Tissue conditioning & soft reline Atraumatic restorative therapy Dress changes Tooth re-implantation Administer local anesthetic, nitrous oxide 1

2 Scope of practice Under Indirect Supervision Emergency palliative treatment of dental pain Place and remove space maintainers Prepare cavities Restore primary and permanent teeth Place temporary crowns Prepare and place preformed crowns Pulpotomies on primary teeth Indirect & direct pulp capping on primary/permanent teeth Stabilize re-implanted teeth Extract primary teeth Remove sutures Brush biopsies Repair defective prosthetic devices Re-cement permanent crowns Outcomes assessment In statute: The Board of Dentistry shall evaluate the impact of dental therapists on the delivery of and access to dental services & report to legislature by 2/15/14 based on the following outcome measures: Number of d.t. annually licensed beginning 2011; Settings where d.t. are practicing & populations served Number of complaints & basis for each complaint Number of disciplinary actions taken In consultation with DHS, BOD shall also develop a process that focuses on assessing impact of d.t. in terms of patient safety, cost-effectiveness & access, focusing on the following outcome measures: number of new patients served reduction in waiting times for needed services decreased travel time for patients impact on emergency room usage for dental care costs to the public health care system Advanced Dental Therapist Qualifications: Complete a dental therapy education program Pass an examination Be licensed as a dental therapist 2,000 hours of dental therapy clinical practice Graduate from a masters advanced dental therapy education program Pass a board-approved certification examination to demonstrate competency Apply for certification Scope of practice Advanced Dental Therapists under general supervision Oral evaluation and assessment of dental disease and the formulation of an individualized treatment plan authorized by the collaborating dentist All services and procedures of a dental therapist Non-surgical extractions of permanent teeth Periodontally diseased Tooth mobility of +3 or +4 Provide, dispense & administer analgesics, anti-inflammatories & antibiotics Supervision: General Practice settings: Same as dental therapist Next steps: Dental Therapist Board of Dentistry write rules and regulations regarding licensure for dental therapists. establish criteria for approving dental therapy education programs and/or identifying approved national accrediting organizations. approve competency-based clinical examination required for licensure. administered independently of an institution providing dental therapy education establish renewal procedures for licensure. evaluate the impact of the use of dental therapists on the delivery of and access to dental services and report to legislature. in consultation with the MDH, evaluate process focusing on accessing the impact of dental therapists in terms of patient safety, cost effectiveness and access. Next steps: Advanced Dental Therapist Develop the curriculum, determine length of study, identify appropriate education sites. Determine content, format, and administration protocols for Board approved certification examination. Board of Dentistry write rules and regulations re: licensure, approval of educational programs & accrediting bodies CDE For dental offices: integrating new providers into dental team For dental therapists: ongoing skills & patient management sessions 2

3 Site visits to recognized dental therapist programs First Nations University Prince Albert, Saskatchewan, Canada 32 years in operation University of Otago, School of Dentistry Dunedin, New Zealand 70+ years in operation University of Sheffield, Faculty of Dentistry Sheffield, England 25+ years in operation State of Minnesota Delegation University of Minnesota (6) Minnesota State College and Universities (3) Central Administration Metropolitan State University Mankato State University Minnesota Dental Association (2) Minnesota Board of Dentistry (1) Site visits to recognized dental therapist programs First Nations University Prince Albert, Saskatchewan, Canada 32 years in operation University of Saskatoon College of Dentistry First Nations University Prince Albert Saskatchewan, Canada 3

4 Lesson learned from Canada visit Site visits to recognized dental therapist programs Without a dental school-based program the profession did not embrace dental therapists. May 29-30, 2008 First Nations University Prince Albert, Saskatchewan, Canada 30+ years in operation August 1-3, 2008 University of Otago, School of Dentistry Dunedin, New Zealand 70+ years in operation Minneapolis 47 o North 94 o West Dunedin 45 o South 170 o East University of Otago School of Dentistry Dunedin, New Zealand Lesson learned from visit to New Zealand Site visits to recognized dental therapist programs First Nations University Prince Albert, Saskatchewan, Canada 32 years in operation University of Otago, School of Dentistry Dunedin, New Zealand 70+ years in operation University of Sheffield, Faculty of Dentistry Sheffield, England 25+ years in operation Educating dental therapy students with dental students creates a professional partnership. 4

5 Lesson learned from visit to England University of Sheffield Faculty of Dentistry Sheffield, England Having the dentist on site builds patient confidence and trust in dental therapists. SOD Curriculum Steering Committee Chair, Judith Buchanan, Associate Dean for Academic Affairs Darryl Hamamoto, Assistant Dean for Academic Affairs Gary Hildebrandt, Director, Division of Operative Dentistry Chris Blue, Director, Division of Dental Hygiene Peter Berthold, Director, Division of Community Oral Health Ron Grothe, Director, Advanced Training Program Pediatric Dentistry Guiding Principles for SOD Curriculum Steering Committee: Dental Therapist The standard of care taught to dental therapists will be identical to that taught to dental students; Within the defined scope of practice, competency requirements for dental therapists will be identical to those which apply to dental students; Examination, diagnosis & treatment planning are the purview of the dentist; Health promotion & disease prevention will be core elements of the educational program; Irreversible surgical procedures will be performed under indirect supervision; Guiding Principles for SOD Curriculum Steering Committee: Dental Therapist Program will be structured to complement, rather than compete with, other dental professionals; Program will provide a foundation for professional advancement and career growth; Graduates will contribute to reducing the cost of care and to improving access for underserved populations; Education will occur in a professional environment which includes dental hygienists & dentists, to ensure graduates are prepared to work in a team setting; Graduates will find viable career opportunities in the dental marketplace; and Program could be replicable by other dental schools. 5

6 Dental Therapist Tracks Bachelor of Science in Dental Therapy for high school graduates undergraduate degree 40 months in length Master in Dental Therapy for adult learners professional degree 2 o emphasis public health, leadership and education 28 months in length Bachelor in Dental Therapy: Curriculum Map Yr 1 Yr 2 S Yr 3 S Y 4 Liberal education requirements Dental courses Pre-clinical courses Clinical courses Moos Tower Outreach experiences Master in Dental Therapy: Programs in Dental Therapy Curriculum Map Yr 2 S Yr 3 Yr 1 S Yr Prerequisite courses Dental courses Pre-clinical courses Clinical courses Moos Tower Outreach experiences Prerequisites or part of program Compositional Writing 4 credits General Biology 4 credits Principles of General Chemistry 4 credits Human Physiology 4 credits Biochemistry 3 credits Statistics 4 credits Psychology 4 credits Intensive Writing 4 credits Human Anatomy 3 credits Microbiology 3 credits 6

7 Curriculum of Program Fall 2009 Head and Neck Anatomy Introduction to Psychomotor Skills Oral Anatomy Lecture and Lab* Dental Therapy Care Process; Clinical Application I Prerequisite courses or elective courses in one of three tracks Education Public Health Leadership Curriculum of Program Spring 2010 Provider Patient Relationship Oral Histology and Embryology* Cariology and Applied Nutrition in Dental Therapy Care Oral and Maxillofacial Radiology* Prerequisite or elective courses * Course taken with dental students * Course taken with dental students Curriculum of Program Curriculum of Program Summer-2010 General and Oral Pathology Local Anesthesia and Pain Management Pharmacology Oral and Maxillofacial Radiology II Lec & Lab* Applied Biomaterials* Periodontology I* Preclinical Pediatric Dentistry* Operative Lec & Lab* I Fall-2010 Dental Public Health and Academic Service Learning I Ethics and Jurisprudence for the Dental Therapist* Operative Dentistry II & III* Preventive Pediatric Dentistry Clinic* * Course taken with dental students * Course taken with dental students Curriculum of Program Spring-2011 Management and Supervision of a Dental Practice* Research Methods Dental Public Health and Academic Service Learning II Comprehensive Care Clinic* Radiology/Operative/DAU/Pediatric Clinics* * Course taken with dental students Curriculum of Program Summer Comprehensive Care Clinic* Operative/DAU/Radiology/Pediatric Clinics* Outreach Experiences* Team Building Course* Fall-2011 Comprehensive Care Clinic* Operative/DAU/Radiology/Pediatric Clinics* Outreach Experiences* Graduation December 2011 * Course taken with dental students 7

8 Dental Therapist Psychomotor skill development achieved in a stateof-the-art facility under the direction of expert dental faculty. Dental Therapist Clinical training in the patient clinics at the dental school, as well as at its urban and rural community outreach clinics. Costs: Tuition and fees (per degree) BSDT Tuition = ~$43,000 (Resident), $58,500 (NR) Fees = ~$20,000 Total = ~$63,000 (Resident), $78,500 (NR) MDT Tuition = ~$39,000 (Resident), $65,000 (NR) Fees = ~$19,000 Total = ~$58,000 (Resident), $84,000 Research Teams organized with specific goals Experts from dentistry, public health, health policy Attitudes of current students, staff and faculty Attitudes of current patients Placement of graduates Salaries of graduates Impact on access to care 8

9 University of Minnesota School of Dentistry Profile of the Dental Therapy Fall 2009 Incoming Class Information on Inaugural Class Number of Students in the Class Men 9 1 Women 8 Ethnically Diverse 2 (%) %) (%) (25 (%) (25 %) %) Overall GPA Masters Level Students Prerequisite GPA Bachelors Level Student In State 8 Out of State 1 Experience in Health Care 6 Seventeen interviewed Interviewed by trained team of two Wrote impromptu essay Completed critical thinking evaluation Evaluation on Advanced Simulation Criteria Evaluated on potential for meeting mission of program 25 Total Completed Applications Updated 08/04/09 JK Dental therapy students (2009) Program Bachelor Background dental hygienist Master dental assistant (4) dental technician new college grads (2) biotech junior scientist Opportunities for the Specialty of Orthodontics 1. Expand scope of services offered 2. Orthodontic Therapists The UK Model 9

10 Expand scope of services offered Preventive oral hygiene instruction fluoride applications Restorative primary and secondary dentition Extractions primary teeth Benefits improve oral hygiene care and enhance caries resistance maximize utility of patient visits use underused clinical space increase clinic revenue Orthodontic Therapists The UK Model Driven by access to care especially rural areas cost of educating time to educate lack of trained auxiliaries cost of care GDC Orthodontic Therapy Course Orthodontic Therapists One year course developed to train individuals as Orthodontic Therapists 4 week core course at Leeds Dental Institute 8 additional study days throughout the year workplace training in an approved practice satisfactory workplace reports; successful completion of end-term assessments; and a project Eligibility: dental nurse, dental hygienist, dental therapist, or dental technician A Diploma in Orthodontic Therapy General Orthodontic therapists are registered dental professionals who carry certain parts of orthodontic treatment under prescription and close supervision of a dentist, who is an orthodontist on the Specialist Orthodontic register of the GDC Orthodontic Therapists SOP Clean and prepare tooth surfaces for orthodontic treatment Identify, select, use and maintain appropriate instruments Insert passive removable orthodontic appliances Insert active removable orthodontic appliances adjusted by a dentist Remove fixed appliances, orthodontic adhesives and cement Take impressions Pour, cast, and trim study models Make a patient s orthodontic appliance safe in the absence of a dentist Orthodontic Therapists SOP Fit orthodontic headgear Fit orthodontic facebows which have been adjusted by a dentist Take occlusal records including orthognathic facebow readings Place brackets and bands Prepare, insert, adjust, and remove archwires Give advice on appliance care and oral health instruction Fit tooth separators Fit bonded retainer Make appropriate referrals to other healthcare professionals 10

11 Additional skills which orthodontic therapists could develop during their career include: Applying fluoride varnish to the prescription of a dentist Repairing the acrylic component part of orthodontic appliances Measuring and recording plaque indices and gingival indices Removing sutures after the wound has been checked by a dentist Orthodontic Therapists The UK Model in 2000 The issues being debated: Length of training Funding Location Final examination NHS Fees Pollard T. Practice Management Forum 2000 British Journal of Orthodontics Orthodontic Therapists The UK Model 2000 The quality of care, if orthodontic therapists assist orthodontists, should improve, as perhaps greater time could be spent on diagnosis, and overall supervision and progress of treatment. Pollard T. Practice Management Forum 2000 British Journal of Orthodontics I m absolutely delighted to see the first Orthodontic Therapists qualify. They will now make a significant impact on the number of patients accessing orthodontic care. Sarah Bain Head of Dental Care Professional training, University Hospital Bristol, 2008 Bristol Orthodontist Therapy Course Bristol Orthodontist Therapy Course Expectations: Increase productivity, efficiency, and treatment standards Reduction in the clinical workload for specialists Increase time for specialists to do treatment planning and finishing procedures Reduce the cost in training the orthodontic workforce Although the permitted duties of an orthodontic therapist seem to be quite clear, there has been some confusion as to the circumstance under which they are able to perform these duties. Qualified orthodontic therapists must work under the prescription of a dentist. Bain S, Lee W, Day C, Ireland A, Sandy J. Orthodontic therapists the first Bristol cohort; Brit Dent J. 2009; Bain S, Lee W, Day C, Ireland A, Sandy J. Orthodontic therapists the first Bristol cohort; Brit Dent J. 2009;

12 Bristol Orthodontist Therapy Course Bristol Orthodontist Therapy Course The principle author of the article is concerned: There is no requirement for the orthodontic therapist to be in the same premises as the orthodontist who had provided that prescription when the treatment is carried out. Bain S, Lee W, Day C, Ireland A, Sandy J. Orthodontic therapists the first Bristol cohort; Brit Dent J. 2009; The effect of the introduction of orthodontic therapists, along with a number of other changes in orthodontic provision are yet to be fully realised. Bain S, Lee W, Day C, Ireland A, Sandy J. Orthodontic therapists the first Bristol cohort; Brit Dent J. 2009; Lessons to be learned from the UK experience Need to monitor further developments in the UK scope of practice level of supervision degree of professional oversight impact on access to care Be vigilant about what s going on at home access to care issues at all levels legislators perceptions, concerns, and ideas state funding for care to the underserved Everyone has a part to play be a part of the solution find your own way support Smiles Change Lives initiative establish or maintain a contact with your legislative representatives This was not just about creating a new member of the dental team Supporting the U-M, AHC & SOD core missions Showing that the U-M can effectively contribute to a state agenda Working with others in developing new & innovative approaches to health care delivery Demonstrating leadership locally and nationally Forging partnerships with professional and legislative stakeholders and lay communities Accessing new resources from groups, agencies, etc. Increasing awareness of the challenges faced by many Minnesotans Midwestern Society of Orthodontists Broadening Your Perspectives Orthodontics and Beyond Patrick M. Lloyd, DDS, MS Dean and Professor, Division of Prosthodontics University of Minnesota School of Dentistry 12